Upon finding a school-age child having a seizure, what should be the nurse’s first action after lowering the client to the floor?

Choice A rationale
While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient’s health.
Choice B rationale
A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient’s health.
Choice C rationale
Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention.
Choice D rationale
While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient’s health.

Choice A rationale
Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis.
Choice B rationale
Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system.
Choice C rationale
Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia.
Choice D rationale
Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system’s response to hypoglycemia.